University of Iowa investigators are beginning a yearlong study to better understand why HPV (human papillomavirus) vaccine coverage in rural areas of the state lags behind other adolescent immunizations.

The study, funded by the National Cancer Institute through the Holden Comprehensive Cancer Center, will be led by a team from Holden. Natoshia Askelson, assistant professor of community and behavioral health in the UI College of Public Health, is the project director. Other partners include the Iowa Primary Care Association, Iowa Department of Public Health, American Cancer Society, Iowa Cancer Consortium, and local public health agencies.

The HPV vaccine protects against a number of diseases and HPV-related cancers such as cervical cancer and oral cancer, but vaccination rates across Iowa are below the national average. According to the most recent data available, only 21 percent of 13- to 15-year-olds in Iowa had completed the HPV vaccination series in 2015. Federal health officials have a goal of 80 percent vaccination completion for adolescents by 2020.

The UI researchers will look at rural counties to explore the various factors that may influence uptake of the HPV vaccine in rural areas.

“This vaccine is nearly 100 percent effective at preventing cancer, so we want to make sure that all adolescents in Iowa have the opportunity to benefit from this vaccine when they are getting their other adolescent vaccines,” says Askelson. “Our work will identify how we can better support rural communities and clinics so that all children will have access to this vaccine.”

A study by University of Iowa researchers found that only a small number of Iowa Medicaid beneficiaries knew about and took part in a new incentive program designed to waive health insurance premiums for enrollees who complete certain healthy activities.

As part of Iowa’s Medicaid expansion efforts, the state created the Healthy Behaviors Program, an optional service designed to waive monthly premiums for Medicaid beneficiaries who get an annual physical and complete a health risk assessment. Launched in 2014, the program was designed to reduce the state’s Medicaid costs by encouraging preventive health practices among beneficiaries.

Brad Wright

But Natoshia Askelson, assistant professor of community and behavioral health, and Brad Wright, assistant professor of health management and policy, along with coauthors from the University of Iowa Public Policy Center, found that no more than 17 percent of those enrolled in the Healthy Behaviors Program had a physical examination and a health risk assessment in the program’s first year. The research findings, based on examinations of claims data and interviews with clinic managers and Medicaid expansion enrollees, were published in the journal Health Affairs.

Certain populations, including younger members, men, non-whites, members with fewer interactions with the health care system, and those who have been enrolled in the program for fewer months, were found to be less likely to complete the healthy activities.

“Given that failure to complete these activities is likely to result in members being charged premiums, and non-payment of premiums can result in disenrollment from the program, these findings raise concerns about the possibility of exacerbating disparities in insurance coverage and, ultimately, health outcomes,” says Wright.

Natoshia Askelson

When researchers interviewed Medicaid members and clinic managers, they found few people were even aware of the program. The UI research raises questions about whether the incentive program can succeed without expanded communication and promotional efforts.

“If you’re going to do some kind of incentive program, you really need to work hard at developing awareness,” says Askelson.

In addition, the researchers say the findings raise questions about whether a program promoting personal responsibility can be viable in the face of the significant challenges facing many beneficiaries covered under Medicaid expansion.

Researchers discovered that some members couldn’t find an available appointment or a provider to accept their health plan. Others had trouble finding the time or transportation to attend an appointment. This population also tends to be more transient and have lower levels of literacy, says Askelson.

Natoshia M. Askelson, MPH, PhD, assistant professor in the Department of Community and Behavioral Health at the UI College of Public Health, has been named principal investigator of the Cancer Prevention and Control Research Network (CPCRN) collaborating center at the University of Iowa. The CPCRN is a national network of academic, public health, and community partners who work together to reduce the burden of cancer, especially among those disproportionately affected. The Iowa collaborating center, affiliated with the College of Public Health’s Prevention Research Center, is funded by the Centers for Disease Control and Prevention and the National Cancer Institute. The University of Iowa joined the CPCRN in 2014, and is one of eight institutions that participate as collaborating centers nationally.

“We are very pleased to have someone with Dr. Askelson’s experience in cancer prevention and control as the PI of the CPCRN collaborating center at Iowa,” says Edith Parker, DrPH, professor and head of community and behavioral health and director of the Prevention Research Center. “Her expertise in research and applied evaluation in issues related to cancer prevention and control will benefit our investigators as well as our community partnerships.”

The University of Iowa collaborates with other CPCRN centers to investigate areas of research interest, including initiatives to increase Human Papillomavirus (HPV) vaccination rates and colorectal cancer screening rates. Currently, CPCRN investigator Jason Daniel-Ulloa, PhD, clinical assistant professor in the Department of Community and Behavioral Health, is working in the community of West Liberty, Iowa, to establish sustainable community-clinical partnerships aimed at increasing HPV vaccination rates in Latinos. In addition, Askelson and Parker contribute to a collaborative workgroup that is examining the use of evidence-based colorectal cancer screening interventions in Federally Qualified Health Centers.